Summary

19.1 Nutritional Disorders

• Diet—both what you eat and how much you eat—has a dramatic impact on health. Eating too much or too little food can lead to serious medical issues, including cardiovascular disease, cancer, anorexia, and diabetes, among others.
• An unhealthy diet combined with unhealthy environmental conditions, such as smoking, significantly increases the potential medical complications.
• Obesity is defined as abnormal or excess fat accumulation and a state of malnutrition by excess and is the result of having a chronic positive energy balance from consuming more calories than are being used by the body.
• Diagnostics and laboratory studies for patients with obesity will generally focus on ruling out other comorbidities or health conditions.
• Care for patients with obesity is individualized, according to any underlying causes of obesity and any comorbid conditions. Treatment includes behavioral interventions, nutritional modification, medications, and surgical intervention, if appropriate.
• Bariatric surgery is a consideration for patients with a BMI of 40 kg/m² or patients with a BMI of 35 kg/m² with significant health issues that would be expected to improve with weight loss.
• Anorexia nervosa is an eating disorder characterized by the maintenance of a body weight well below average through severe dietary restriction and/or excessive exercise. Patients with anorexia nervosa have deficits in dopamine and serotonin neurotransmitters, which are responsible for eating behavior, reward, impulse control, and neuroticism.
• Psychiatric evaluation and diagnosis of anorexia nervosa is based on criteria provided by the American Psychiatric Association. These criteria include the patient having a distorted view of themselves and their condition, intense fear of gaining weight, and a significantly low body weight from severe conscious restriction of calories.
• The primary patient outcome for anorexia nervosa management is an increase in caloric intake to sustain healthy bodily function.
• Malabsorption occurs when the GI tract is unable to properly absorb nutrients, such as proteins, carbohydrates, fats, vitamins, minerals, or trace elements. This can occur with one vitamin or macronutrient, several, or all. Malabsorption can occur at any phase of the digestion and absorption of food: luminal, mucosal, or postabsorptive.
• Medical treatment of malabsorption is focused on finding and treating the underlying cause of malabsorption, avoiding any food triggers, and managing symptoms.

19.2 Disorders of the Oral Cavity

• Dental caries are common chronic oral cavity diseases, even though they are easily preventable with good oral hygiene.
• In the inpatient setting, it is important for nurses to provide mouth care for patients who are unable to perform self-care.
• Cancer of the oral cavity or oropharynx can develop on the tissue of the mouth and gums, on or under the tongue, and at the back of the mouth or throat.
• The priorities of care during treatment are maintaining a patent airway and healthy nutritional status and providing emotional support, pain relief, and patient education. Frequent airway assessments may need to be completed.
• Temporomandibular disorder (TMD) is a collection of more 30 disorders that cause pain and dysfunction of jaw movement; research suggests it is caused by a combination of psychological stressors, life stressors, genes, jaw trauma, grinding the teeth, and arthritis or other inflammatory conditions.
• TMD is usually a temporary disorder that resolves without aggressive treatment.

19.3 Parenteral and Enteral Nutrition

• Parenteral nutrition is a concentrated IV solution containing glucose, amino acids, minerals, electrolytes, and vitamins, administered via a large central IV line.
• Parenteral nutrition is typically used when the patient’s intestines or stomach are not working properly and must be bypassed, such as during paralytic ileus, in which peristalsis has completely stopped, or after postoperative bowel surgeries, such as bowel resection.
• Peripheral TPN is typically used for shorter-term nutritional support or for a patient who cannot tolerate or does not desire a central line.
• Enteral nutrition (EN) refers to nutrition provided directly into the GI tract through an enteral tube that bypasses the oral cavity. EN may be indicated in patients with mental illness, neuromuscular disorders, upper GI obstruction, and traumatic injuries, such as burns or traumatic brain injury.
• Nursing management of the patient receiving parenteral nutrition includes verifying the parenteral nutrition order, assessing the patient’s response to the infusion, and monitoring for complications.
• The most serious complication of enteral feeding is inadvertent respiratory aspiration of gastric contents, causing life-threatening aspiration pneumonia. Other complications include tube clogging, tubing misconnections, and patient intolerance to the feeding.

19.4 Disorders of the Upper GI System

• Barrett’s esophagus is a condition in which the cells that line the esophagus change and become more like intestinal cells. It is more common in men and usually diagnosed around age 55 years.
• Barrett’s esophagus is frequently asymptomatic, and patients tend to have other symptoms of GI conditions, such as frequent heartburn and acid regurgitation or reflux.
• Symptom improvement and patient understanding of the importance of diet modification and medication adherence are the goals of treatment for Barrett’s esophagus.
• Patients diagnosed with Barrett’s esophagus are prescribed a proton pump inhibitor (PPI), such as omeprazole or pantoprazole, to eliminate gastroesophageal reflux disease (GERD) symptoms and prevent further esophageal irritation.
• Gastritis is inflammation and redness of the lining of the stomach; it may be acute or chronic, and erosive and nonerosive. Once the underlying cause is treated, it usually resolves.
• Patients with acute gastritis may present with epigastric pain, nausea, vomiting, or a feeling of fullness in the upper abdomen after eating.
• Endoscopy with biopsy is the gold standard for diagnosing gastritis, and treatment can be singular, or a combination of antibiotics, PPIs, vitamin supplementation, immunomodulatory therapy, and dietary modifications.
• Gastric cancer, or stomach cancer, is the fifth most frequently diagnosed cancer and the third leading cause of cancer deaths worldwide; most patients with symptoms will present with advanced disease.
• Potential treatments for stomach cancer may include surgery, chemotherapy, radiation therapy, targeted drug therapy, and immunotherapy.

19.5 Disorders of the Lower GI System

• Constipation is defined as a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.
• In more serious cases, constipation can be a sign of fecal impaction, intestinal obstruction, or paralytic ileus; treatment typically includes a prescribed daily bowel regimen, such as oral stool softeners and a mild stimulant laxative
• Diarrhea is caused by increased peristalsis causing the stool to move too quickly through the large intestines for water to be effectively reabsorbed, resulting in loose, watery stools; many conditions can cause diarrhea.
• Maintaining adequate fluid intake is the priority of care for a patient with diarrhea.
• Irritable bowel syndrome (IBS) is a disorder of the large intestine that causes changes in bowel movements and abdominal pain. It can occur after infection, be triggered by stress, or be caused by food intolerances, brain-gut interaction, and inflammatory processes.
• Because IBS is a symptom-based disorder, treatment is aimed at symptom resolution.
• In patients with celiac disease, the ingestion of gluten causes the body’s immune system to attack the villi of the small intestine; this results in permanent damage over time, causing a scalloping of the folds and a cracked appearance of the mucosa, and disrupts the absorption of nutrients.
• Treatment for celiac disease is a lifelong, strict, gluten-free diet.
• Colorectal cancer is often detected before symptoms occur; patients who present with symptoms usually have advanced disease.
• Appendicitis is most often caused by an obstruction within the appendiceal orifice. This creates an inflammatory response, which can lead to local ischemia and perforation.
• Diverticular disease occurs when diverticulosis becomes symptomatic, such as such as with lower abdominal pain, bloating, and diarrhea.
• Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the GI tract; the two main types of IBD are Crohn’s disease and ulcerative colitis.
• Treatment goals are to induce remission of IBD and maintain management of the disease.

19.6 Hepatic and Biliary Disorders

• Jaundice is a symptom of gallbladder or liver disease. It is yellowing of the skin or sclera.
• Liver failure causes bleeding and jaundice, contributes to blood sugar management, can cause decreased level of consciousness and neurological status, and medication toxicity. It can be acute.
• Hepatic encephalopathy causes impairment of judgment and coordination; in later stages, coma can occur.
• Cirrhosis is a hardening of the liver, causing blood flow through the liver to be difficult.
• Hepatitis can occur from viruses and nonviral causes, including toxins and being drug induced. The liver is inflamed.
• A liver transplant may be considered for many conditions. The challenges with a transplant are the possibility of organ rejection and living with being immunocompromised.
• Gallbladder dysfunctions can include cholecystitis and cholelithiasis. These disorders may also cause jaundice and pain. Endoscopic retrograde cholangiopancreatography (ERCP) to remove a gallstone or gallbladder removal surgery (usually laparoscopically) may be required.
• Pancreatitis dysfunction includes pancreatitis and pancreatic cancer. Pancreatitis can be acute or chronic. Pancreatitis refers to inflammation of the pancreas. Acute pancreatitis treatment focuses on fluid and electrolyte balance, pain management, GI rest, glucose management, and nutritional support. For chronic pancreatitis, pancreatic enzymes will be taken daily.
• Pancreatic cancer is usually far progressed before it is diagnosed. Most patients are past the point of being eligible for surgery when diagnosed. The mortality rate is low at the 5-year mark (12.5%). Hyperglycemia may be present. The surgical procedure that can be performed is called the Whipple procedure.

19.7 Ostomy Care

• Ostomies are surgically placed when the bowel is unable to work or is diseased.
• Placement of a stoma may be an ileostomy (connects to the ileum) or a colostomy (connects to the colon above the ileum).
• Extensive teaching is required, including appliance use, self-catheterization of a continent ileostomy, or frequent bowel movements for the ileal pouch.
• Emotional adjustment is a factor.